Basic Information
| Provider Information | |||||||||
| NPI: | 1548382211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLYNN | ||||||||
| FirstName: | VEDA | ||||||||
| MiddleName: | ROCHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13042 LORETTA DR | ||||||||
| Address2: | |||||||||
| City: | NORTH TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927051820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143369611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 460 E CARSON PLAZA DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907463228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105239500 | ||||||||
| FaxNumber: | 3102252725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF42762 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 00007570 | 05 | CA | MEDICAID | CBSC825 | 01 | CA | LA DMH PROVIDER | OTHER |